Risk Of ICU Death Research Articles

Establishment of MELD-lactate clearance scoring system in predicting death risk of critically ill cirrhotic patients

BackgroundTo develop a scoring system related to the lactate clearance (ΔLA) to predict the mortality risk (MELD-ΔLA) for critically ill cirrhotic patients.MethodsIn this retrospective cohort study, 881 critically ill cirrhotic patients from the Medical Information Mart for Intensive Care (MIMIC-III) database were included eventually. The outcomes of our study were defined as ICU death, 28-day, 90-day and 1-year mortality. Predictors were identified by multivariate Cox analysis to develop the predictive scoring system. The C-index and area under the curve (AUC) of receiver operator characteristic curve (ROC) were used to identify the predicting performance of the MELD-ΔLA, sequential organ failure assessment (SOFA), chronic liver failure-sequential organ failure assessment (CLIF-SOFA), the model for end-stage liver disease (MELD), Child–Pugh, chronic liver failure consortium acute-on-chronic liver failure (CLIF-C ACLF), chronic liver failure consortium-acute decompensation (CLIF-C AD) and MELD-Na scoring systems. Additionally, subgroup analysis was also performed based on whether critically ill cirrhotic patients underwent liver transplantation.ResultsCreatinine, bilirubin, international normalized ratio (INR), lactate first, ΔLA and vasopressors were closely associated with ICU death of liver critically ill cirrhotic patients. The C-index of the MELD-ΔLA in ICU death was 0.768 (95% CI 0.736–0.799) and the AUC for the MELD-ΔLA scoring system in predicting 28-day, 90-day, and 1-year mortality were 0.774 (95% CI 0.743–0.804), 0.765 (95% CI 0.735–0.796), and 0.757 (95% CI 0.726–0.788), suggested that MELD-ΔLA scoring system has a good predictive value than SOFA, CLIF-SOFA, MELD, Child–Pugh, CLIF-C ACLF, CLIF-C AD) and MELD-Na scoring systems. Additionally, the study also confirmed the good predictive value of MELD-ΔLA scoring system for critically ill cirrhotic patients regardless of undergoing liver transplantation.ConclusionThe developed MELD-ΔLA score is a simple scoring system in predicting the risk of ICU death, 28-day, 90-day and 1-year mortality for critically ill cirrhotic patients, which may have a good predictive performance.

Nucleated red blood cells as predictors of mortality in patients with acute respiratory distress syndrome (ARDS): an observational study

BackgroundNucleated red blood cells (NRBCs) in critically ill patients are associated with increased mortality and poor outcome. The aim of the present study was to evaluate the predictive value of NRBCs in patients with acute respiratory distress syndrome (ARDS).MethodsThis observational study was conducted at an ARDS referral center and included patients from 2007 to 2014. Daily NRBC counts were assessed and the predictive validity of NRBCs on mortality was statistically evaluated. A cutoff for prediction of mortality based on NRBCs was evaluated using ROC analysis and specified according to Youden’s method. Multivariate nonparametric analysis for longitudinal data was applied to prove for differences between groups over the whole time course. Independent predictors of mortality were identified with multiple logistic and Cox’ regression analyses. Kaplan–Meier estimations visualized the survival; the corresponding curves were tested for differences with the log-rank test.ResultsA total of 404 critically ill ARDS patients were analyzed. NRBCs were found in 75.5% of the patients, which was associated with longer length of ICU stay [22 (11; 39) vs. 14 (7; 26) days; p < 0.05] and higher mortality rates (50.8 vs. 27.3%; p < 0.001). Logistic regression analysis with mortality as response showed NRBC positivity per se to be an independent risk factor for mortality in ARDS with a doubled risk for ICU death (OR 2.03; 95% CI 1.16–3.55; p < 0.05). Also, NRBC value at ICU admission was found to be an independent risk factor for mortality (OR 3.25; 95% CI 1.09–9.73, p = 0.035). A cutoff level of 220 NRBC/µl was associated with a more than tripled risk of ICU death (OR 3.2; 95% CI 1.93–5.35; p < 0.0001). ARDS patients below this threshold level had a significant survival advantage (median survival 85 days vs. 29 days; log rank p < 0.001). Presence of a severe ARDS was identified as independent risk factor for the occurrence of NRBCs > 220/µl (OR 1.81; 95% CI 1.1–2.97; p < 0.05).ConclusionsNRBCs may predict mortality in ARDS with high prognostic power. The presence of NRBCs in the blood might be regarded as a marker of disease severity indicating a higher risk of ICU death.

SM-08 * NEURO-ONCOLOGICAL PATIENTS ADMITTED IN INTENSIVE-CARE UNIT (ICU): PATIENT'S CHARACTERISTICS, PREDICTIVE FACTORS OF DEATH IN ICU AND FUNCTIONAL OUTCOME

BACKGROUND: Prognostic of oncological patients admitted in ICU is considered pejorative with a high mortality rate. To date, outcome of neuro-oncological patients admitted in ICU was never explored. Our objective was to analyze the characteristics, predictive factors of death in ICU and functional outcome after ICU for neuro-oncological patients. METHODS: Retrospective study of all patients with primary brain tumor admitted in our institutional ICU for medical indications between January 2002 and December 2012. Functional status was evaluated before first symptom associated to ICU admission and after ICU. Predictive impact on the risk of death in ICU was analyzed using the chi square test and the Mann-Whitney U-test. RESULTS: 71 patients were admitted in the ICU(≈3% of our patients); 22% died in ICU. Half of them had glioblastoma. ICU admission indications were mainly refractory seizures(41%) and septic shock(17%). At admission, 16% had multi-organ failure. Ventilation was necessary for 41%, catecholamines for 13%. 9% of patients received chemotherapy in ICU. Predictive factors associated to an increased risk of death in ICU were: non-neurological cause of admission(p = 0.022), multiple organ failures(p < 0.001), respiratory(p < 0.001), hemodynamic(p < 0.001), hepatic(p = 0.003) or renal dysfunction(p = 0.023). Longer delay between first symptom and ICU admission tended to increase this risk (p = 0.083). On the contrary, abnormal Glasgow score(p = 0.205) as well as tumor type(p = 0.678), tumor control status(p = 0.380) and number of previous lines(p = 0.409) were not associated to an increased risk of death in ICU. None of the patients receiving chemotherapy died in ICU. Among the 35 evaluable patients, 77% presented with a stable or improved Karnofsky Performance Status after ICU hospitalization as compared to ongoing status before ICU related disease. CONCLUSION: In patient with malignant brain tumor,admitted in ICU, predictive factors of death appear to be similar to those described in non-oncological patients. ICU hospitalization is generally not associated with a subsequent decrease of functional status.

Improved prognosis of septic shock in patients with cirrhosis: a multicenter study*.

To determine the evolution of the outcome of patients with cirrhosis and septic shock. A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data. The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area. Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis. None. Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04). The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.

Prognostic impact of no ST segment elevation resolution in acute myocardial infarction complicated by cardiogenic shock

Background : ST segment resolution (RST), during fibrinolysis therapy (FT) for acute myocardial infarction (AMI), is a good marker of myocardial reperfusion. The in-hospital mortality increases with time to reperfusion when cardiogenic shock (CS) complicates AMI. Objectives: The aim of this study is to assess the no-RST during prehospital fibrinolysis for ST segment elevation myocardial infarction (STEMI) complicated by CS as an early predictor of mortality for triage. Method : In a cohort of 643 patients, receiving prehospital FT for STEMI (pain to FT, mean time 120mn), 39 patients had STEMI complicated by CS. ECG was performed prior starting the FT, baseline ECG, and on ICU admission, admission ECG (FT to ICU, mean time 55mn).Two classes of RST were defined : no resolution (RST 30%).ICU mortality was investigated for each class of RST within 30 days. Results : Results are shown in the table below. No-RST on admission ECG is significantly (p<0.05) correlated to a higher ICU mortality rate when STEMI is complicated by CS. Conclusion : No-RST, during the first hour of FT for STEMI complicated by CS, predicts no myocardial reperfusion and high risk of ICU death within 30 days. This clinical marker is easy to perform at bedside, and should participate to an early scoring system for decision making. STEMI patients CS patients STEMI mortality(%) CS mortality (%)